Circulation reports最新文献

Background: Recently, shock teams have been introduced to optimize cardiogenic shock (CS) care; however, their clinical benefits remain unclear. We conducted a systematic review and meta-analysis to assess whether management by a shock team improves outcomes in patients with CS.

Methods and results: This meta-analysis was conducted according to the PRISMA guidelines. Studies comparing adults with CS managed with or without a shock team were identified from the PubMed, Web of Science, and Cochrane Library databases. The primary outcome was short-term mortality (cardiac intensive care unit, in-hospital, or 30-day mortality); the secondary outcome was bleeding. Of the 7 retrospective cohort studies that met the inclusion criteria, 3 without a critical risk of bias were included in the analysis. Shock team management was significantly associated with lower short-term mortality (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.32-0.85; P=0.010) and bleeding complications (OR 0.62; 95% CI 0.43-0.91; P=0.010). Sensitivity analysis using crude data also supported the mortality benefit (OR 0.68; 95% CI 0.54-0.85; P<0.010). However, no randomized trials were included, and the certainty of evidence was rated very low owing to the risk of bias and inconsistency.

Conclusions: Shock team management may improve short-term outcomes in patients with CS; however, the level of evidence is very low. Further prospective studies are needed to evaluate optimal shock team composition and roles.

Background: Comprehensive monitoring of cardiovascular disease (CVD) is essential in rapidly aging societies such as Japan. The Japanese Circulation Society (JCS) launched the Japanese Registry Of All cardiac and vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) registry, linking annual JROAD questionnaires with nationwide DPC administrative claims to enable patient-level analyses of hospitalized CVD care. This Protocol Paper presents a comprehensive overview of the registry.

Methods and results: Using anonymized data (April 2012-March 2023), we described temporal trends in patient demographics, principal CVD diagnoses, major interventions, disease-specific severity, and hospital characteristics. From FY2012-FY2022, participating facilities increased from 610 to 860, with registered patients more than doubling. Median age rose from 73.0 to 75.0 years; patients aged ≥90 years nearly quadrupled. The proportion of angina pectoris admissions declined (26.8% to 11.7%), while absolute numbers remained stable. Atrial fibrillation/flutter admissions rose in both proportion (4.1% to 5.9%) and absolute number. Heart failure admissions increased steadily, with its proportion showing a U-shaped trend. Catheter ablations for atrial fibrillation/flutter increased over fivefold, exceeding 64,000, while percutaneous coronary interventions for acute myocardial infarction surpassed 46,000.

Conclusions: JROAD-DPC now captures over 1.5 million annual CVD hospitalizations, providing a nationwide, large-scale longitudinal view of cardiovascular care in Japan. Its scale and validated coding enable robust analyses of trends and outcomes, supporting national CVD policy evaluation and improvement.

Background: B-type natriuretic peptide (BNP) is a key biomarker for heart failure (HF) and widely used for risk stratification. Elevated BNP levels in acute stroke are linked to poor outcomes, but its prognostic value in the post-acute phase remains unclear.

Methods and results: This retrospective study included 876 patients admitted to a rehabilitation hospital after acute cerebral infarction or hemorrhage between February 2019 and December 2022. Patients were classified into 4 groups based on BNP or N-terminal prohormone of BNP. The primary outcome was all-cause unfavorable events, including in-hospital death or transfer due to worsening condition. The severely elevated BNP group had a significantly higher risk of all-cause unfavorable events (hazard ratio: 2.34; 95% confidence interval: 1.26-4.32) than the normal group. No significant difference was observed in the mildly or moderately elevated BNP groups. BNP showed superior predictive value over HF diagnosis in terms of area under the receiver operating characteristic curve (0.712 vs. 0.691), net reclassification improvement (0.304, P=0.002), and integrated discrimination improvement (0.025, P=0.015). Higher BNP was associated with lower body mass index, reduced estimated glomerular filtration rate, longer time from stroke onset, atrial fibrillation, and cardioembolic stroke.

Conclusions: BNP levels in the post-acute stroke phase were significantly associated with unfavorable outcomes and may serve as a useful prognostic marker.

Background: Studies of off-loading devices for chronic limb-threatening ischemia (CLTI) are scarce. We investigated (1) the effect of the application of early therapy sandals on changes in the Clinical Frailty Scale (CFS) scores of patients with CLTI before and after hospitalization, and (2) adverse events such as wound deterioration and reamputation.

Methods and results: We retrospectively analyzed the cases of 51 patients (51 limbs) with toe amputation after revascularization and compared 2 groups: patients who did not apply any load during the off-loading duration and focused on resistance training (the 'usual rehabilitation' group), and those who used therapeutic sandals and performed walking and aerobic exercises with partial off-loading from an early stage (the 'orthotic' rehabilitation group). The before-to-after hospitalization change in the CFS score was 0 (-1, 0) in the usual rehabilitation group, and 0 (0, 1) in the orthotic rehabilitation group (P=0.002), a significant difference. There were no significant between-group differences in wound healing duration (usual rehabilitation group, 48 [19,76.5] days; orthotic rehabilitation group, 41 [27.5,78.8] days) or reamputation rate (usual rehabilitation group, 5 [22%]; orthotic rehabilitation group, 3 [11%]).

Conclusions: The early postoperative use of therapeutic sandals tended to shorten the duration of complete off-loading after toe amputation due to CLTI and to help maintain CFS scores throughout the hospitalization duration. It was also shown to have a minimal impact on treatment delay and reamputation.

Background: Catheter ablation (CA) is a well-established therapy for arrhythmia, but the impact of CA strategies has not been thoroughly investigated. Nagano Prefecture comprises a large geographical area and some hospitals do not have cardiac surgeons, thus limiting the application of CA strategies. The aim of this study was to investigate the detailed strategies for CA in Nagano Prefecture and to clarify their efficacy and safety.

Methods and results: The Shinshu Catheter Ablation (Shinshu-AB) Registry is a multicenter prospective observational registry. Patients treated with CA for any type of arrhythmia are included. Data on the target arrhythmia(s), CA strategy, outcomes, and complications were collected and analyzed at Shinshu University Hospital. The study was approved by the institutional review boards of all investigational sites and registered in the UMIN Clinical Trials Registry (UMIN-55562). Primary endpoints were the composite incidence of arrhythmia recurrence, procedure-related adverse events, and cardiovascular events. The secondary endpoints were acute success, chronic success for >12 months, and all-cause death.

Conclusions: The Shinshu-AB Registry provides real-world data from the Nagano Prefecture on the outcomes and complications of CA for various types of arrhythmias.

Background: Although metabolic dysfunction-associated fatty liver disease is typically diagnosed using ultrasonography, the fatty liver index (FLI) offers a simple alternative. Brachial-ankle pulse wave velocity (baPWV) is an established marker of arterial stiffness and a predictor of cardiovascular events. This study investigated the association between FLI and baPWV in a general Japanese population.

Methods and results: This cross-sectional study included participants aged ≥18 years, excluding those with atrial fibrillation, lower extremity artery disease, severe aortic stenosis, or missing data. The primary outcome was an elevated baPWV (≥1,800 cm/s). Multivariable logistic regression analysis was performed to assess the association between FLI and elevated baPWV, considering FLI both as a categorical variable (low risk: FLI <30; moderate risk: FLI ≥30 and <60; high risk: FLI ≥60) and as a continuous variable (per 10-unit increase). The analysis included 10,122 individuals (mean age 54.3 years; 55% male). In multivariable-adjusted models, the odds of elevated baPWV were significantly higher in the moderate-risk (odds ratio [OR] 1.47; 95% confidence interval [CI] 1.20-1.79) and high-risk (OR 1.78; 95% CI 1.33-2.38) groups, using the low-risk group as the reference category. Each 10-unit increase in FLI was associated with significantly higher odds of the outcome (OR 1.16; 95% CI 1.10-1.22).

Conclusions: FLI showed a significant association with arterial stiffness in the general Japanese population.

Background: The advent of transcatheter aortic valve implantation (TAVI) has increased the rate of aortic valve treatment in frail older adults. Factors contributing to frailty include sarcopenia (characterized by reduced muscle mass), osteopenia (characterized by decreased bone mineral density), and the newly termed osteosarcopenia, which is characterized by a simultaneous decline in muscle mass and bone mineral density. In this study, we aimed to investigate the impacts of sarcopenia, osteopenia, and osteosarcopenia on the clinical outcomes of TAVI.

Methods and results: We retrospectively analyzed 490 patients who underwent TAVI for aortic stenosis at Yamaguchi University Hospital between April 2014 and March 2025. Osteopenia, sarcopenia, and osteosarcopenia were diagnosed by preprocedural computed tomography. Patients were classified into normal (N), sarcopenia alone (S), osteopenia alone (O), and osteosarcopenia (OS) groups. Early clinical outcomes and 1-year survival rates exhibited no significant differences among the groups. However, the 5-year survival rates were 94.1%, 77.6%, 60.4%, and 46.5% in the N, S, O, and OS groups, respectively (P<0.05). The Cox proportional hazards model revealed osteosarcopenia as a significant risk factor for late death (hazard ratio, 2.09; P=0.0002).

Conclusions: Preoperative evaluation of muscle mass and bone density aids in stratifying TAVI risk.

Background: Because the optimal choice of vasopressor for the initial treatment of cardiogenic shock (CS) remains controversial, we conducted a systematic review and meta-analysis to evaluate whether noradrenaline improves clinical outcomes compared with other vasopressors (adrenaline, dopamine, and vasopressin) in patients with CS.

Methods and results: PubMed, CENTRAL, and Web of Science databases were searched for randomized controlled trials (RCTs) and observational studies comparing noradrenaline with other vasopressors in adults with CS. A meta-analysis was conducted using fixed-effect models where appropriate. Two RCTs were included (n=337). One trial enrolled 57 patients and compared the effects of noradrenaline and adrenaline. Another study included 280 patients with CS as a subgroup and compared noradrenaline with dopamine. Pooled analysis showed that noradrenaline likely reduced the 28-day mortality rate compared with other vasopressors (very-low certainty). This corresponded to approximately 110 fewer deaths per 1000 patients (95% confidence interval: 217 fewer to 5 fewer). Secondary outcomes from the Levy study indicated fewer adverse events in the noradrenaline group.

Conclusions: Noradrenaline likely reduces the 28-day mortality rate compared with other vasopressors (very-low certainty) in CS. Given the small number of studies and the potential bias, further large-scale trials are warranted.

Background: Enteral nutrition (EN) is often delayed in critically ill cardiovascular patients due to concerns about bowel ischemia, especially when under vasopressor or mechanical support. We evaluated the impact of a structured EN protocol designed to promote timely and safe nutrition delivery in the Cardiac Care Unit (CCU).

Methods and results: This single-center retrospective study compared mechanically ventilated CCU patients before (April 2019-March 2020) and after (April 2022-March 2023) protocol implementation. The protocol specified hemodynamic safety thresholds and used a peptide-based formula. Outcomes included EN-related complications, time to EN initiation, and nutritional adequacy within the first week. A total of 116 patients (58 per group) were analyzed. No significant differences were observed in vomiting (P=0.717), diarrhea (P=0.219), or bowel ischemia (P=0.364). The post-protocol group showed a significantly shorter time to EN initiation (median 39.5 vs. 76.0 h; P<0.001). By Day 5, enteral energy adequacy improved (40.8% vs. 12.3%; P<0.001), and protein adequacy increased (62.2% vs. 31.0%; P<0.001). Exploratory analyses showed no significant differences in CCU stay, ventilator-free days, or in-hospital deaths.

Conclusions: The EN protocol enabled earlier initiation and improved EN delivery in high-risk CCU patients without increasing complications, offering a safe and practical approach to narrowing the gap between guidelines and practice.

Background: Managing heart failure complicated by severe right heart failure with implantable mechanical circulatory support remains a significant challenge. One therapeutic strategy is biventricular assist device (BiVAD) support, typically involving the off-label use of 2 implantable left ventricular assist devices (LVADs). Because the available data of implantable BiVAD support remain limited, we reviewed the data for 6 patients on implantable BiVAD support.

Methods and results: Between January 2010 and March 2019, 6 patients underwent BiVAD implantation at Osaka University Hospital. Their mean age was 31±11 years, and 2 (33%) were male. The right ventricular assist devices (RVADs) utilized were Jarvik2000 (Jarvik Heart, NY, USA) in 4 patients (67%), and HVAD (HeartWare, Framingham, MA, USA) in 2 patients (33%). The survival rates at 1 and 3 years after BiVAD implantation were 83% and 67%, respectively. Of the 6 patients, 4 underwent heart transplantation at 553, 709, 791, and 1,245 days, respectively, following RVAD implantation; 2 patients died during follow-up at 280 and 511 days, respectively, after RVAD implantation. Stroke occurred in 3 patients. Hemolysis or pump thrombosis occurred in 3 patients. Heart failure occurred in 3 patients. Device-related infection occurred in 1 patient.

Conclusions: Although implantable BiVAD support provided a feasible bridge to transplantation with favorable survival, the high incidence of complications indicates that significant challenges remain in optimizing patient outcomes and emphasizes the necessity for RV-specific device development.